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Acute Coronary Syndrome

Acute Coronary Syndrome. Objectives. Define & delineate acute coronary syndrome Review Management Guidelines Unstable Angina / NSTEMI STEMI Review secondary prevention initiatives. Scope of Problem (2004 stats). CHD single leading cause of death in United States

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Acute Coronary Syndrome

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  1. Acute Coronary Syndrome

  2. Objectives • Define & delineate acute coronary syndrome • Review Management Guidelines • Unstable Angina / NSTEMI • STEMI • Review secondary prevention initiatives

  3. Scope of Problem (2004 stats) • CHD single leading cause of death in United States • 452,327 deaths in the U.S. in 2004 • 1,200,000 new & recurrent coronary attacks per year • 38% of those who with coronary attack die within a year of having it • Annual cost > $300 billion

  4. Expanding Risk Factors • Smoking • Hypertension • Diabetes Mellitus • Dyslipidemia • Low HDL < 40 • Elevated LDL / TG • Family History—event in first degree relative >55 male/65 female • Age-- > 45 for male/55 for female • Chronic Kidney Disease • Lack of regular physical activity • Obesity • Lack of Etoh intake • Lack of diet rich in fruit, veggies, fiber

  5. Similar pathophysiology Similar presentation and early management rules STEMI requires evaluation for acute reperfusion intervention Unstable Angina Non-ST-Segment Elevation MI (NSTEMI) ST-Segment Elevation MI (STEMI) Acute Coronary Syndromes

  6. At least 2 of the following Ischemic symptoms Diagnostic ECG changes Serum cardiac marker elevations Diagnosis of Acute MI STEMI / NSTEMI

  7. Diagnosis of Angina • Typical angina—All three of the following • Substernal chest discomfort • Onset with exertion or emotional stress • Relief with rest or nitroglycerin • Atypical angina • 2 of the above criteria • Noncardiac chest pain • 1 of the above

  8. Diagnosis of Unstable Angina • Patients with typical angina - An episode of angina • Increased in severity or duration • Has onset at rest or at a low level of exertion • Unrelieved by the amount of nitroglycerin or rest that had previously relieved the pain • Patients not known to have typical angina • First episode with usual activity or at rest within the previous two weeks • Prolonged pain at rest

  9. Unstable Angina STEMI NSTEMI • Non occlusive • thrombus • Non specific • ECG • Normal cardiac • enzymes • Occluding thrombus • sufficient to cause • tissue damage & mild • myocardial necrosis • ST depression +/- • T wave inversion on • ECG • Elevated cardiac • enzymes • Complete thrombus • occlusion • ST elevations on • ECG or new LBBB • Elevated cardiac • enzymes • More severe • symptoms

  10. Acute Management • Initial evaluation & stabilization • Efficient risk stratification • Focused cardiac care

  11. Evaluation Occurs simultaneously • Efficient & direct history • Initiate stabilization interventions Plan for moving rapidly to indicated cardiac care Directed Therapies are Time Sensitive!

  12. Chest pain suggestive of ischemia Immediate assessment within 10 Minutes • 12 lead ECG • Obtain initial cardiac enzymes • electrolytes, cbc lipids, bun/cr, glucose, coags • CXR Initial labs and tests Emergent care History & Physical • IV access • Cardiac monitoring • Oxygen • Aspirin • Nitrates • Establish diagnosis • Read ECG • Identify complications • Assess for reperfusion

  13. Aid in diagnosis and rule out other causes Palliative/Provocative factors Quality of discomfort Radiation Symptoms associated with discomfort Cardiac risk factors Past medical history -especially cardiac Reperfusion questions Timing of presentation ECG c/w STEMI Contraindication to fibrinolysis Degree of STEMI risk Focused History

  14. Recognize factors that increase risk Hypotension Tachycardia Pulmonary rales, JVD, pulmonary edema, New murmurs/heart sounds Diminished peripheral pulses Signs of stroke Examination Vitals Cardiovascular system Respiratory system Abdomen Neurological status Targeted Physical

  15. ECG assessment ST Elevation or new LBBB STEMI ST Depression or dynamic T wave inversions NSTEMI Non-specific ECG Unstable Angina

  16. Normal or non-diagnostic EKG

  17. ST Depression or Dynamic T wave Inversions

  18. ST-Segment Elevation MI

  19. New LBBB QRS > 0.12 sec L Axis deviation Prominent R wave V1-V3 Prominent S wave 1, aVL, V5-V6 with t-wave inversion

  20. Troponin ( T, I) Very specific and more sensitive than CK Rises 4-8 hours after injury May remain elevated for up to two weeks Can provide prognostic information Troponin T may be elevated with renal dz, poly/dermatomyositis CK-MB isoenzyme Rises 4-6 hours after injury and peaks at 24 hours Remains elevated 36-48 hours Positive if CK/MB > 5% of total CK and 2 times normal Elevation can be predictive of mortality False positives with exercise, trauma, muscle dz, DM, PE Cardiac markers

  21. % % % % Mortality at 42 Days % % 831 174 148 134 50 67  Prognosis with Troponin

  22. UA or NSTEMI - Evaluate for Invasive vs. conservative treatment - Directed medical therapy Risk Stratification Based on initial Evaluation, ECG, and Cardiac markers STEMI Patient? YES NO - Assess for reperfusion - Select & implement reperfusion therapy - Directed medical therapy

  23. Cardiac Care Goals • Decrease amount of myocardial necrosis • Preserve LV function • Prevent major adverse cardiac events • Treat life threatening complications

  24. STEMI cardiac care • STEP 1: Assessment • Time since onset of symptoms • 90 min for PCI / 12 hours for fibrinolysis • Is this high risk STEMI? • KILLIP classification • If higher risk may manage with more invasive rx • Determine if fibrinolysis candidate • Meets criteria with no contraindications • Determine if PCI candidate • Based on availability and time to balloon rx

  25. Fibrinolysis indications • ST segment elevation >1mm in two contiguous leads • New LBBB • Symptoms consistent with ischemia • Symptom onset less than 12 hrs prior to presentation

  26. Absolute contraindications for fibrinolysis therapy in patients with acute STEMI • Any prior ICH • Known structural cerebral vascular lesion (e.g., AVM) • Known malignant intracranial neoplasm (primary or metastatic) • Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours • Suspected aortic dissection • Active bleeding or bleeding diathesis (excluding menses) • Significant closed-head or facial trauma within 3 months

  27. Relative contraindications for fibrinolysis therapy in patients with acute STEMI • History of chronic, severe, poorly controlled hypertension • Severe uncontrolled hypertension on presentation (SBP greater than 180 mm Hg or DBP greater than 110 mmHg) • History of prior ischemic stroke greater than 3 months, dementia, or known intracranial pathology not covered in contraindications • Traumatic or prolonged (greater than 10 minutes) CPR or major surgery (less than 3 weeks) • Recent (within 2-4 weeks) internal bleeding • Noncompressible vascular punctures • For streptokinase/anistreplase: prior exposure (more than 5 days ago) or prior allergic reaction to these agents • Pregnancy • Active peptic ulcer • Current use of anticoagulants: the higher the INR, the higher the risk of bleeding

  28. STEMI cardiac care • STEP 2: Determine preferred reperfusion strategy Fibrinolysis preferred if: • <3 hours from onset • PCI not available/delayed • door to balloon > 90min • door to balloon minus door to needle > 1hr • Door to needle goal <30min • No contraindications PCIpreferred if: • PCI available • Door to balloon < 90min • Door to balloon minus door to needle < 1hr • Fibrinolysis contraindications • Late Presentation > 3 hr • High risk STEMI • Killup 3 or higher • STEMI dx in doubt

  29. Comparing outcomes

  30. Comparing outcomes

  31. Medical TherapyMONA + BAH • Morphine(class I, level C) • Analgesia • Reduce pain/anxiety—decrease sympathetic tone, systemic vascular resistance and oxygen demand • Careful with hypotension, hypovolemia, respiratory depression • Oxygen(2-4 liters/minute) (class I, level C) • Up to 70% of ACS patient demonstrate hypoxemia • May limit ischemic myocardial damage by increasing oxygen delivery/reduce ST elevation

  32. Nitroglycerin(class I, level B) • Analgesia—titrate infusion to keep patient pain free • Dilates coronary vessels—increase blood flow • Reduces systemic vascular resistance and preload • Careful with recent ED meds, hypotension, bradycardia, tachycardia, RV infarction • Aspirin(160-325mg chewed & swallowed) (class I, level A) • Irreversible inhibition of platelet aggregation • Stabilize plaque and arrest thrombus • Reduce mortality in patients with STEMI • Careful with active PUD, hypersensitivity, bleeding disorders

  33. Beta-Blockers(class I, level A) • 14% reduction in mortality risk at 7 days at 23% long term mortality reduction in STEMI • Approximate 13% reduction in risk of progression to MI in patients with threatening or evolving MI symptoms • Be aware of contraindications (CHF, Heart block, Hypotension) • Reassess for therapy as contraindications resolve • ACE-Inhibitors / ARB(class I, level A) • Start in patients with anterior MI, pulmonary congestion, LVEF < 40% in absence of contraindication/hypotension • Start in first 24 hours • ARB as substitute for patients unable to use ACE-I

  34. Heparin (class I, level C to class IIa, level C) • LMWH or UFH(max 4000u bolus, 1000u/hr) • Indirect inhibitor of thrombin • less supporting evidence of benefit in era of reperfusion • Adjunct to surgical revascularization and thrombolytic / PCI reperfusion • 24-48 hours of treatment • Coordinate with PCI team (UFH preferred) • Used in combo with aspirin and/or other platelet inhibitors • Changing from one to the other not recommended

  35. Additional medication therapy • Clopidodrel(class I, level B) • Irreversible inhibition of platelet aggregation • Used in support of cath / PCI intervention or if unable to take aspirin • 3 to 12 month duration depending on scenario • Glycoprotein IIb/IIIa inhibitors(class IIa, level B) • Inhibition of platelet aggregation at final common pathway • In support of PCI intervention as early as possible prior to PCI

  36. Additional medication therapy • Aldosterone blockers(class I, level A) • Post-STEMI patients • no significant renal failure (cr < 2.5 men or 2.0 for women) • No hyperkalemis > 5.0 • LVEF < 40% • Symptomatic CHF or DM

  37. STEMI care CCU • Monitor for complications: • recurrent ischemia, cardiogenic shock, ICH, arrhythmias • Review guidelines for specific management of complications & other specific clinical scenarios • PCI after fibrinolysis, emergent CABG, etc… • Decision making for risk stratification at hospital discharge and/or need for CABG

  38. Unstable angina/NSTEMI cardiac care • Evaluate for conservative vs. invasive therapy based upon: • Risk of actual ACS • TIMI risk score • ACS risk categories per AHA guidelines Low High Intermediate

  39. Risk Stratification to Determine the Likelihood of Acute Coronary Syndrome

  40. TIMI Risk Score Predicts risk of death, new/recurrent MI, need for urgent revascularization within 14 days

  41. ACS risk criteria Low Risk ACS No intermediate or high risk factors <10 minutes rest pain Non-diagnositic ECG Non-elevated cardiac markers Age < 70 years Intermediate Risk ACS Moderate to high likelihood of CAD >10 minutes rest pain, now resolved T-wave inversion > 2mm Slightly elevated cardiac markers

  42. High Risk ACS Elevated cardiac markers New or presumed new ST depression Recurrent ischemia despite therapy Recurrent ischemia with heart failure High risk findings on non-invasive stress test Depressed systolic left ventricular function Hemodynamic instability Sustained Ventricular tachycardia PCI with 6 months Prior Bypass surgery

  43. Low risk Intermediate risk High risk Chest Pain center Conservative therapy Invasive therapy

  44. Invasive therapy option UA/NSTEMI • Coronary angiography and revascularization within 12 to 48 hours after presentation to ED • For high risk ACS (class I, level A) • MONA + BAH(UFH) • Clopidogrel • 20% reduction death/MI/Stroke – CURE trial • 1 month minimum duration and possibly up to 9 months • Glycoprotein IIb/IIIa inhibitors

  45. Conservative Therapy for UA/NSTEMI • Early revascularization or PCI not planned • MONA + BAH(LMW or UFH) • Clopidogrel • Glycoprotein IIb/IIIa inhibitors • Only in certain circumstances (planning PCI, elevated TnI/T) • Surveillence in hospital • Serial ECGs • Serial Markers

  46. Secondary Prevention • Disease • HTN, DM, HLP • Behavioral • smoking, diet, physical activity, weight • Cognitive • Education, cardiac rehab program

  47. Secondary Preventiondisease management • Blood Pressure • Goals < 140/90 or <130/80 in DM /CKD • Maximize use of beta-blockers & ACE-I • Lipids • LDL < 100 (70) ; TG < 200 • Maximize use of statins; consider fibrates/niacin first line for TG>500; consider omega-3 fatty acids • Diabetes • A1c < 7%

  48. Secondary preventionbehavioral intervention • Smoking cessation • Cessation-class, meds, counseling • Physical Activity • Goal 30 - 60 minutes daily • Risk assessment prior to initiation • Diet • DASH diet, fiber, omega-3 fatty acids • <7% total calories from saturated fats

  49. Thinking outside the box…

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